The campaign for Indigenous health equality within a generation

The campaign for Indigenous health equality within a generation

Speech to the Department of Premier and Cabinet, Adelaide

By Tom Calma

Aboriginal and Torres Strait Islander Social Justice Commissioner

Human Rights and Equal Opportunity Commission

September 18, 2007

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Slide A

I begin by acknowledging the Kaurna people, the traditional owners of the land where we meet today and pay my respects to their elders.  I would also like to thank the Department for the Premier and Cabinet and, in particular, Sonia Waters of the Social Inclusion unit for inviting me to speak to you today and I acknowledge my fellow speakers April and Nerida.

Part i:  my role and introduction to the campaign

Many of you will know that, as the Aboriginal and Torres Strait Islander Social Justice Commissioner, I am required to report annually to the federal parliament on the status of enjoyment and exercise of human rights by Indigenous Australians.  This is called the Social Justice Report. 

My 2005 report included a chapter titled ‘Achieving Aboriginal and Torres Strait Islander health equality within a generation:  a human rights approach’ based on the right to health. It is here that I set out my recommendations for the campaign for indigenous health equality that I am speaking to today. This chapter has since been published as a stand alone publication and there are copies available today.

I have fairly limited time with you today, so what I am going to do is set out the main features of the campaign and look at how it fits with the broad South Australian approach towards indigenous health. But I would urge you to look at the published versions of the campaign also as there are some important elements of it I will be skimming over here today.

Slide B

Part ii: indigenous health inequality

I am sure I do not need to remind you of the extent of indigenous health equality in Australia.  The headline indicator – one that is well known – is life expectation. Nationally over 1996–2001, there was an estimated difference of approximately 17 years between indigenous and non-indigenous life expectation.  And the last time the Australian Bureau of Statistics produced an indigenous life expectation figure for this state, in 2001, it was about a year and a half lower still.

But the overall point I want to make about indigenous health equality is that it is an entrenched health crisis. The prevalence of chronic diseases in particular mean there is no magic bullet,  rather, a comprehensive, long term address and plan is needed.    

Slide C

Part iii:  understanding indigenous health inequality

So how do we understand indigenous health inequality? 

What I want to highlight here is that indigenous peoples’ health suffers because we suffer an inequality of opportunity to be as healthy as other Australians. We have significantly less access to primary health care and the health infrastructure in indigenous communities is of a poorer standard than that in other Australian communities. 

In 2004, in the 'Bettering the evaluation and care of health' or beach survey it was estimated that indigenous peoples enjoyed 40% of the per capita access of the non-indigenous population to primary health care provided by mainstream general practitioners. Of course there are aboriginal community controlled health services that supplement the mainstream services but the gaps that are still evident indicate an outstanding “need” shortfall ranging from $250 to $570 million per annum depending on the quality of service offered.

And no doubt many of you will be aware that in 2003 the final report of the South Australian generational health review identified aboriginal people in this state as suffering an inequitable distribution of primary health care (although it did not attempt to quantify this).   And there have been others:    the 2003 Layton review and the coronial inquests into deaths from petrol sniffing, for example, have identified similar shortfalls.

‘Health infrastructure’ is a term I am using to describe all the things that support good health, but that are not health services. Examples include:  potable water supplies, healthy food, healthy housing,  sewerage and sanitation, and so on.

The dominant feature of health infrastructure inequality in Australia relates to indigenous peoples’ housing. Nationally, 5.5% of indigenous households live in overcrowded conditions. More broadly, in relation to roads, sanitation, water supplies and electricity, a century of neglect of infrastructure in indigenous communities nationally has left what could be, according to ATSIC in 2001, a $3-4 billion project for this generation.

And providing these things boils down to Australian governments planning effectively and committing the needed resources.   

Slide D

Part iv: the campaign

Addressing these fundamental social justice issues – and remember, we are talking about ensuring equality of opportunity here, not special treatment -- should make a huge difference to indigenous health in Australia.

Internationally it has been demonstrated that optimally and consistently resourced primary health care systems can make a significant difference to the health status of populations, as measured by life expectancy.  For example, in the 1940s to the 1950s in the united states,  native American life expectancy improved by about 9 years;  and an increase in life expectancy of about twelve years took place in New Zealand over two decades from the 1940s to the 1960s.

And yet while spending has increased on primary health care (as well as things like health infrastructure), there is no ambitious plan to meet this primary health care need as soon as possible in the current national indigenous health policy:  the national strategic framework for Aboriginal and Torres Strait Islander health.

This has as its goal the achievement of indigenous health equality. However, it does not set a timeframe for achieving this.

In fact at the national and state level there are a number of strategies and commitments in relation to indigenous health. These provide a substantial foundation from which to address indigenous health inequality.

However, governments of all persuasions have not, generally speaking, activated their commitments by setting them within an achievable time frame. They have instead left the achievement of equality to an unspecified future time. By doing so, all Australian governments have been largely unaccountable for progress in achieving indigenous health equality and they have not matched their commitments with the necessary funds and program support to realise them.

Accordingly, the key issue for indigenous health – and the focus of the indigenous health equality campaign -- remains the need to implement the extensive commitments of governments and to ensure that the quantum and pace of activities is sufficient to achieve the goal of addressing indigenous health inequality.

And that is why I have recommended that Australian governments commit to achieving equality of health status and life expectation between indigenous and non-indigenous people within 25 years.

A particularly vital secondary target proposed is that Australian governments should also commit to achieving equal access to primary health care and health infrastructure within 10 years for indigenous peoples. I would urge the South Australian government to support the adoption of these targets nationally, as well as use them here.

Aboriginal community controlled health organisations have a vital role to play in the provision of primary health care. However, the expansion of community controlled health services must take place alongside efforts to improve the accessibility of mainstream services. 

In relation to mainstream services, can I note how pleased I was to see in South Australia’s Health Care Plan 2007 -2016, the plans for Port Augusta hospital to become a centre of excellence for indigenous health as well as note that aboriginal health was one of the specialised services that all the GP-plus centres that service aboriginal populations in this state will offer over the next ten years.

Particular attention must also be paid to the engagement and empowerment of indigenous peoples in any address to health inequality. 

It is common sense that governments risk failure if they develop and implement policies about indigenous issues without engaging with the intended recipients of those services. Bureaucrats and governments can have the best intentions in the world, but if their ideas have not been subject to the ‘reality test’ of the life experience of the local indigenous peoples who are intended to benefit from this, then government efforts will fail in the medium to long term. 

Slide E

Part v: South Australia and the campaign

So how can South Australia align itself with the campaign, or reflect the principles of the right to health and the health campaign in its overall policy approach?

First, by setting time bound targets for its main indigenous policy objectives.

I am happy to say that, to some degree, you are.

South Australia’s revised 2007 strategic plan contains nine goals focused on the needs of Aboriginal South Australians.   I highlight in particular:

Target 6.9 aboriginal housing: reduce overcrowding in aboriginal households by 10% by 2014.

Target 2.6 chronic disease: increase, by 5 percentage points, the proportion of people living with chronic disease whose self-assessed health status is good or better.

In other areas of the plan, there are some missed opportunities in the sense that the goals are not linked to targets. For example:

Target 2.5 aboriginal healthy life expectancy: lower the morbidity and mortality rates of Aboriginal South Australians

Target 6.3 (new) early childhood – birth weight: reduce the proportion of low birth weight babies.

In relation to other areas, (and I am sure its absence is plain to all after the first part of my speech), indigenous peoples’ equality of access to primary health care is critically important and I would urge the state to adopt this as a goal in its strategic plan, and that it be linked to targets – ten years if possible.

And there are reasons for this state to feel confident in adopting time bound targets:

• You have a relatively small indigenous population. At the last census there were just over 26,000 people identified as indigenous in the state. That is 1.7% of the population. So we are not talking huge numbers here.

• You have a track record of success. For example, according to the bureau of statistics infant mortality rates have reduced in this state from 10.4 to 7.7 deaths per thousand births since 2000. While there is always room for improvement, that is a significant reduction and the fact that you have made such inroads into the burden of indigenous health inequality already I would hope would encourage you to set targets in this and other key areas.

The second way the state can work towards the campaign or in a way that is aligned with it is to work with the community controlled health sector. But here I believe I am ‘preaching to the converted’ -- can I note happily what I understand is the strong relationship between the state government and the Aboriginal Health Council of South Australia and the integration of AHCSA within the South Australian health sector.

In South Australia, the strength and high standing of the community controlled health sector across the state, and the success stories that have come from them are outstanding (particularly when it has worked with the state government).

While time does not permit me to do these justice here, I highlight Nganampa health and its work with the South Australian government (among others) towards reducing petrol sniffing to record low levels across the Apy lands – and let us not forget what a blight on this states’, and the Northern Territory’s reputation this was for years.

Can I also mention Pika Wiya and its Anangu Bibi maternal care program and Nunkunwarrin Yunti and its ‘tune into your health’ health promotion program for indigenous young people are other stellar examples that should only inspire confidence that together the state government and the community controlled health sector can work to find real solutions to problems that have plagued indigenous health in this state for years.

In particular, now that the SA government’s Mullighan inquiry is looking into the sexual abuse of children in the Apy lands, can I impress the point that whatever recommendations come from this inquiry that the government work with indigenous communities and Nganampa health to develop solutions, and solutions that are funded according to need?

A Northern Territory style intervention in these communities would be a disaster. I would invite any of you here to attend the Don Dunstan Oration tonight where I am providing a detailed critical analysis of the intervention. But suffice to say here, it is the imposition of solutions onto communities that is the core criticism I have. That this is not just some abstract ‘rights’ point, but it has profound practical implications: in short, I believe an imposed solution will not work and may in fact set the clock back in terms of the mental and physical health of community members. I welcome reports that Justice Mullighan is talking to Nganampa health in an effort to avoid exactly such an imposed solution approach once his recommendations are made.

Finally, and related to my previous point, I would urge the government to support where possible the expansion of the community controlled health sector in itself and through whatever leverage it may have with the federal government through, for example, the indigenous health planning forums and the commonwealth’s healthy for life chronic diseases program.

I note for example the seed indigenous health services that have begun operations in Whyalla and Mount Gambier, and I would urge the government to help fund these at the levels appropriate to the need of their local indigenous populations.

In finishing, in relation to the campaign, I am pleased to report that over 40 indigenous and non-indigenous organisations are currently working in partnership for Australian governments to commit to the campaign for achieving indigenous health equality within 25 years. 

In December 2006, the coalition of organisations published an open letter calling for an end to indigenous health inequality in The Australian newspaper. In April 2007, Olympians Catherine Freeman and Ian Thorpe helped launch the campaign at the Telstra stadium, Sydney. The partners are currently working towards hosting a national indigenous health summit in February 2008 where we will formally provide Australian governments with targets strategies and timelines to address indigenous health – this is the least we can do to mark the passing of the 40th anniversary of the 1967 referendum.

To finish can I share with you that yesterday the senate agreed, without dissent, that “the need to act ‘to close the gap’ to achieve health equality for Aboriginal and Torres Strait Islanders within a generation is a matter of urgency.”

Thank you, and I am happy to respond to any questions.